MAIL TO: BOTH SIDES OF CLAIM FORM MUST BE COMPLETED AND RETURNED WITHIN 30 DAYS. COPIES OF ITEMIZED BILLS MUST BE ATTACHED Administrative Concepts, Inc. 997 Old Eagle School Road Suite 215 Wayne, PA 19087-1706 www.visit-aci.com ACE American Insurance Company Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. For residents of the following states, please see the re verse side: California, Colorado, District of Columbia, Florida, Maine, Maryland, Ne vada, New Hampshire, New York, Oregon, Pennsylvania, Tennessee,Te xas or Virginia. ❏ ❏ - PLEASE PRINT ALL INFORMATION GRADUATE PARTS I & II - MUST BE COMPLETED AND SIGNED BY STUDENT UNDERGRADUATE Name of College or University, City and State Domestic ❏ Policy Number International ❏ California State University Study Abroad Program Insured Student’s Name LAST NAME M.I. FIRST NAME STUDENT ID Birth Date # PHONE # Present Address Home Address NO. AND STREET CITY OR TOWN STATE ZIP #+4 NO. AND STREET CITY OR TOWN STATE ZIP #+4 If claim for dependent, give dependent’s name COMPLETE THIS SECTION FOR ACCIDENT CLAIM , relationship to Insured Age COMPLETE THIS SECTION FOR SICKNESS CLAIM Exact nature of injury __________________________________________ Date of sickness ______________________________________________ ___________________________________________________________ Date symptoms first noticed _____________________________________ Date and hour of occurrence ___________________________________ If pregnancy, date of last menstrual period _________________________ ___________________________________________________________ Was the injury due to practice or play of a sport? ❏ Yes ❏ No What is the exact nature of the sickness? __________________________ Which sport? ________________________________________________ ___________________________________________________________ ❏ Intercollegiate ___________________________________________________________ ❏ Intramural ❏ Club ❏ Other Is condition work related? ❏ Yes ❏ No Have you ever had the same or similar condition? ❏ Yes ❏ No Is condition due to auto accident ❏ Yes ❏ No If yes, date of first treatment ____________________________________ If yes, please attach detailed policy information on all motor vehicles involved in accident. Date of last treatment _________________________________________ Were you treated in the Health Service for this condition? ❏ Yes ❏ No Were you treated in the Health Service for this condition? ❏ Yes ❏ No Seen by: ______________________________ Date: ______________ Seen by: ______________________________ Date: _____________ If your claim is for services outside of the Health Service, were you referred? ❏ Yes ❏ No If your claim is for services outside of the Health Service, were you referred? ❏ Yes ❏ No If not, why? Away from school ❏ For what reason: ____________________________ If not, why? __________________________________________ Away from school ❏ For what reason: ____________________________ __________________________________________ Administrative Concepts, Inc. does not share private health information except as required or permitted by law. We are committed to guarding the private information entrusted to us. CLAIMANT’S STATEMENTS: Assignments of Benefits - I hereby authorize all eligible expense benefits due me under my student insurance coverage to be paid directly to: Doctor: ❏ Hospital: ❏ California State university International Programs: ❏ Address:________________________________________________________________________ To any medical care provider, medical care facility, Insurer, government-sponsored health plan, or employer: I authorize the release of any medical information about me to Administrative Concepts, Inc.or the underwriting company.This applies to all information about the diagnosis, treatment, or prognosis of any illness or injury I now have or have had in the past.The Company will use this information to determine if my claim is eligible. Any information obtained will not be released by the Company except to my primary health insurance carrier (if any) or persons or organizations performing investigative or legal services for the Company in connection with my claim. A copy of this authorization shall be considered as effective and valid as the original and shall remain in effect for one year from the date of authorization. I certify that the information given by me in support of my claim is tr ue and correct. Patient’s or Authorized Representative’s Signature Date If Authorized Representative, Relationship to Patient or Legal Designation STREET CSU-05 CITY STATE ZIP CODE +4 PART II Please Print All Information Have you been covered (as an insured or dependent) by any other hospital and/or medical plan for the past 12 months? ❏ Yes ❏ No If yes, indicate the name and address of the company ___________________________________________________________ Effective date of coverage: ________________________ Expiration date: _____________________ Policy No. ____________ Have you filed a claim with any other insurance company? ❏ Yes ❏ No I hereby certify that the above information given by me in support of this claim is true and correct. Patient’s or Authorized Representative’s Signature __________________________________________ Date _______________ If Authorized Representative, Relationship to Patient _____________________________________________________________ or Legal Designation ______________________________________________________________________________________ The following section may not be applicable to you if you are not covered under any other medical insurance plan. Mother’s Name _______________________________________ Employer’s Telephone # ______________________________ Employer’s Name and Address ______________________________________________________________________________ Name and Address of Insurance Co. _________________________________________________________________________ _________________________________________________________________________________ Policy No. ____________ Father’s Name _______________________________________ Employer’s Telephone # _______________________________ Employer’s Name and Address ______________________________________________________________________________ Name and Address of Insurance Co. _________________________________________________________________________ _________________________________________________________________________________ Policy No. ____________ Spouse’s Name ______________________________________ Employer’s Telephone # _______________________________ Employer’s Name and Address ______________________________________________________________________________ Name and Address of Insurance Co. _________________________________________________________________________ _________________________________________________________________________________ Policy No. ____________